Taking care of your skin with topical retinoids

retin AThere are a few simple recommendations and practices that should be included in any basic skin care regimen.  Appropriate
moisturization and exfoliation, protection from harmful UV radiation, and avoiding the significant damage caused by harsh toxins such as those found in cigarette smoke are a few such recommendations.  And certainly, in patients with
lighter skin tone, the use of topical retinoids (a class of chemical compounds long used in cosmetic creams and in the treatment of various skin disorders) could be included in this list.

A study published in the Journal of Drugs in Dermatology explores the efficacy and tolerability of two topical treatments for
photoaging, photodamage, and fine lines/wrinkles on the face.  The study compares two commonly used vitamin A derivatives, retinol and tretinoin.

Retinol is an over the counter compound found in many cosmetic creams marketed to treat wrinkles and to rejuvenate the skin.  Tretinoin is a similar more potent compound available by prescription, and is most commonly found in topical acne therapies.  Tretinoin has been used to effectively treat acne for many years, but has also long been used as a prescription strength anti-wrinkle cream.

The study enlisted patients with photodamage (blotchy skin coloring from sun damage) to use retinol on one side of the face and tretinoin on the other for a period of 12 weeks.  And the results from the study were undeniable.  The regular daily use of topical retinoids produced noticeable improvement in photodamage.  Meaning It helped to even tone and texture by lightening brown spots, smoothening rough patches, and fading fine lines.

retinol before and after
Before and after 12 weeks of daily use retinol 5% cream. Notice the subtle improvement in fine lines and dark spots.

Confirmation is always nice, but the fact that topical retinoids help with fine lines is not news.  What I found more interesting however, is that there seemed to be little to no difference in improvement between the retinol and the tretinoin treated sides.  Meaning that both sides of the face improved to similar degrees. The results of this study support the notion that over the counter cosmetic products containing retinol might be similarly effective as the prescription tretinoin formulations. Another reason why this may be good news is that tretinoin creams tend to be more irritating to the skin, causing occasional dryness, flaking, redness, and burning sensation.

It should be noted that there are multiple shortcomings and potential confounding variables in the study, including an obvious conflict of interest as the study was designed, executed, and paid for by a cosmetic skin care company that produces over the counter retinol creams.  As an aside, this particular company makes products that I really like and have found to work well in my own practice.  But I think the take home message for me from this study is unhindered by these questionable detractors. Skin care is important and has an appreciable effect on skin health and appearance weather you use over the counter products
or prescription strength medication.  You only get one face. Take care of it.

Botox for depression

Can botox help patients suffering from depression? Dermatologists and scientific research are finding this is a viable treatment for patients suffering from depression. Dr. Smart of The University of Utah advises patients that botox could be the missing treatment in their struggle with depression.

Positive effects on mood have been seen in patients who’ve had Botox
treatment for the glabella and frown lines (the area above the nose
and between the eyebrows).  And a randomized, double-blinded, placebo controlled trial recently published in the Journal of Clinical Psychiatry adds further evidence to support the use of botox as an adjunctive therapy to treat depression.

In this study a total of 30 patients with high levels of chronic and
treatment-resistant depression were enrolled in the study. Patients
were randomly assigned to receive a single injection of Botox or a
single injection of saline (placebo). Six weeks after a single
treatment, the Botox group had an average 47.1% reduction in
depression symptoms vs. 9.2% in the placebo group.

Why would this work?  Our emotions are expressed by facial muscles,
which in turn send feedback signals to the brain to reinforce those
emotions. Treating facial muscles with botulinum toxin to prevent the
facial muscles from expressing a frown or brooding scowl seems to
interrupt this cycle.

Neither this concept nor the evidence presented here are particularly new, but I never fail to find the link between the physical and the emotional fascinating. Or maybe people are just happy when their wrinkles get better.

Great Lips

lip enhancements are a simple and common procedure at cosmetic physician's offices. Lip enhancement procedures are regularly performed by David Ross Smart, MD at The University of Utah's Department of Dermatology

Great lips are great.

Having full, plump lips is often considered a sign of good health and youth. And symmetric, well-shaped, proportionate lips are generally regarded as an alluring, cross-cultural sign of beauty.  For these reasons injectable lip enhancements are common and popular procedures in the cosmetic physician’s office.

As we age, the lips can slowly lose their fullness and shape.  The distance between the bottom of the nose and the upper lip sags and slightly lengthens, giving the upper lip a longer and thinner appearance.  And adding or restoring volume and shape to the lips is an easy non-invasive way to quickly enhance overall beauty in many patients.

Lip enhancement is simple, quick, and carries immediate reward with relatively low risk.  A good lip enhancement is generally subtle, accentuating the natural shape of the lip, correcting any asymmetry, and sometimes simply adding volume.

When done well, the effect is impressive and patients are very pleased. However, they have not always been done well.   Poorly filled or over-filled lips are readily noticeable, and the picture of someone with those shapeless, overfilled, sausage lips has, over the last couple of decades, become the pop culture poster child of bad cosmetic surgery.  But the majority of good lip enhancements go almost unnoticed because they are natural and subtle.

A good candidate for lip enhancement:

A good candidate is someone who wants to accentuate the shape, improve proportion, or correct some of the volume loss that has happened over time, then they might be a good candidate.

As always with elective cosmetic interventions, motivation and expectations about outcomes are important considerations when deciding if someone is a good candidate.  Is the patient considering lip augmentation to make someone else happy or to try to fit an ideal image? If so, the patient should think twice about it.  Enhanced lips may make your lips plumper and fuller, but you will still be you when you walk out of the doctor’s office.

lips before and after a visit to the cosmetic dermatologist

Before and after photos of a standard cosmetic dermatology procedure by Dr. Smart
before and after 1cc of Juvederm

Lip augmentation is a simple procedure that can be done easily at a cosmetic dermatologist office

before and after images of a lip augmentation performed by David Ross Smart, MD at The University of Utah Department of Dermatology

It is important to remember that not everyone needs their lips filled.  I certainly don’t advocate that.

What to expect during the procedure:

Before the injections, a topical or local numbing agent may be applied to ease discomfort. Sometimes injections can be given before the treatment to completely numb the lips.  After carefully marking the areas to be injected, very fine needles are used to inject the substance into your lips.  Following injection, ice may be given to ease discomfort and control swelling.  Lipstick or other lip products are best avoided immediately after the procedure.  You should be able to notice a difference immediately.

A little more in depth:

Attaining the perfect lip proportions is possible with just a few visits at a cosmetic physician's office

Aesthetic lips:

  • An appropriate upper to lower lip size ratio
  • A distinct cupids bow
  • Fullness and a concave sloping of the upper lip in profile
  • A defined and thick vermilion border
  • A prominence or presence of philtral columns
  • Upturned oral commissures

Aging lips:

  • Flattening of philtral columns
  • Lengthening of the cutaneous upper lip
  • Thinning of the lip and volume loss
  • Convex sloping in profile
  • Downturned oral commissures
  • Loss of the natural vermiliocutaneous pout

The proportions: 

Perfect Lip proportion?
Note that while 1/3 is written, the upper lip is clearly not 1/2 of the size of the lower.

Achieving the perfect lip proportions is possible with simple cosmetic dermatology procedures offered by Dr. Smart at The University of Utah Department of Dermatology

Different sources will state slightly different things. The most commonly quoted is the golden ratio, 1.0:1.6, as demonstrated in the above diagram. However, it has been my experience that these ratios convey perception and  not reality.  Great lips do not quite fit any of these ratios. In fact, even the diagrams used to illustrate the proposed ratios are noticeably erroneous.   Regardless, the point is that the upper lip is proportionally small than the lower.  If you are only injecting the upper lip then you are setting yourself up to fail.  The tubercles of the lower lip must be addressed and evaluated to maintain the appropriate proportion.

What to focus on when evaluating and correcting:

1. Philtral columns
2. Cupids bow
3. Lateral edges of the cupids bow and the white roll of the upper lip
4. Tubercles of the lower lip
5. upturn of the corners of the mouth

Lip enhancement is not a one-size-fits-all procedure, and an aesthetic eye is applied to evaluate the needs of each situation.

Perfect lips for women models

Fraxel Dual, a laser for the brown spots

solar lentigo

Freckles, dark spots, age spots, liver spots, or sun spots. Whatever you want to call them, these brown patches, medically termed lentigo, are typically found on the face and hands and can make us look older than we feel.  Here are some pictures of what I mean:

lentigo blue eye

lentigosolarLentigo_handsolarLentigo_man cheek

There are many ways to get rid of or lighten these pesky brown spots.  While many lasers, chemical peels, and a variety of creams are used to treat these lesions, and treat them effectively, I’ve been very impressed with results from the fraxel dual laser.

The Fraxel is a very popular cosmetic treatment, and it is also used  is used to treat scarring, fine lines and wrinkles as well as lightening the brown spots and smoothening blotchy pigmentation that comes with sun damage.

The Fraxel is considered a facial resurfacing laser that works by creating a checkerboard pattern of thermal or heat energy in the skin. This energy being delivered with laser precision causes specifically placed heat injury to the skin which results in a type of peeling or exfoliation. This in turn causes skin tightening and new collagen formation.  Here are some pictures of results from the fraxel laser when used specifically to treat “lentigo”.

Fraxel lenitgo
After 2 treatments
Before, 2 days after, and 1 week after 1 treatment
Screen Shot 2014-09-23 at 11.09.02 AM
After 2 treatments

The Fraxel is not as aggressive as some other facial resurfacing methods which makes this a comparatively very safe option with little to no downtime depending on each individuals response and how comfortable you are going into work with a little redness and maybe some peeling.  Some mild swelling for a couple of days is not unusual either. And sometimes a few treaments are needed to get the desired effect, especially when using the Fraxel to treat scars and wrinkles.

 

A little more detail:

The Fraxel laser was initially launched as a 1550nm erbium fractionated non-ablative laser. A later model called the Fraxel dual was produced and has the classic 1550mn setting as well as a 1927nm thulium laser setting.

Terms to know from the previous paragraph:

Ablative vs. non-ablative

Ablative lasers are more aggressive as they vaporize the tissue, Non-ablative lasers cause damage to the desired target cells through heat energy, but do not vaporize the tissue.

Fractionate vs. non-fractionated:

Fractionated lasers deliver energy in a checkerboard pattern, which can be beneficial in certain treatments as it leaves zones of untreated skin that make the subsequent healing process more rapid.

.fractionated pattern

The 1550nm setting has been used for years as an effective resurfacing laser for wrinkles and to tighten the skin. The 1927nm setting was added to better target the brown discoloration.

When used to treat wrinkles the results achieved from one treatment of the Fraxel are not nearly as impressive as from one treatment of an ablative laser. The upside however, is that the Fraxel has much less social downtime, and fewer side effects. A series of Fraxel treatments (typically 3 to 6 treatments) at 2- to 4-week intervals is recommended for the best clinical outcome when trying to treat skin laxity and wrinkles. Fewer treatments are necessary when you’re goal is to treat brown spots. Repeated Fraxel treatments can achieve a similar result for acne scars when compared to traditional ablative laser skin resurfacing.   However, the improvement seen after a series of Fraxel treatments for very deep wrinkles around the mouth and eyes often falls short of the impressive results that can be achieved with ablative laser skin resurfacing.

Sunscreen

screen-capture-4
Do you remember these days, pass the baby oil and cocoa butter!

 

I remember in high school when you laid out as much as possible on vacations so you could come back looking like a bronzed goddess! I wish that I was a little smarter back then and took sunscreen and sun protection more seriously, but it’s never too late to start now.

There are two principle ways in which sunscreen blocks UV radiation. The sunscreen either contains compounds that physically block the sun by reflecting the UV rays, or it contains chemicals that absorb the UV radiation before it gets to the skin. They are referred to as physical and chemical blockers respectively.

The UV radiation that reaches the earth’s surface is principally UVA and UVB. The vast majority of UV radiation that reaches our skin is UVA with only a small percentage being UVB. UVA, being that it has longer wavelengths, can penetrate more deeply in the skin, and is not blocked by the glass of a car window. Technically, UVA and UVB do different things to the skin, but both wavelengths cause damage to the DNA, increase the risk of skin cancer, and cause photoaging.

Recently compounds have been developed that are more effective at absorbing a broad range of UV radiation, and sunscreens are now combining chemicals that absorb different portions of the spectrum to create a broad spectrum of protection. Make sure to read the sunscreen and see that it offers “broad spectrum” coverage. Commonly used ingredients that will cover a broad spectrum are avobenzone, and octocrylene.

The most common physical blockers are sunscreens that contain zinc or titanium. Physical blockers are slightly different in that they have always blocked the full spectrum of UV radiation because all they do is reflect the rays. They have been around for a while but they were cumbersome to use initially because the formulations years ago would not rub into your skin. They would simply have to be painted on like a think white paste on the nose. Think of any beach themed movie or TV show from the 80’s or early 90’s. Technology has now dramatically improved the ease and esthetic of their use.

Possibly the most important aspect of sunscreen use is reapplication. Sunscreen does not last for nearly as long as what advertisers would have you believe, and there is no such thing as waterproof when it comes to sunscreen you rub onto your skin. They will all wash off if you’re having fun swimming or sweating. No matter the spf, if its not on your skin it wont work, so remember to reapply every few hours.

People frequently ask for sunscreen recommendations, or about what the best sunscreen is. My answer is the one you use! There are a lot of great sunscreens to choose from and as long as it has an spf of at least 30, good broad spectrum coverage, and you reapply frequently with appropriate amounts, then the rest is just personal preference. There are thick creams, runny lotions, and aerosol sprays, all with a variety of smells and prices attached. Find one that you like and use it.

Our current favorite when it comes to facial sunscreens is the Elta MD UV Clear, with SPF 46. It’s a physical blocker that rubs in clean and smooth and does not leave your face feeling sticky and without an annoying sunscreen smell or residue. The Elta MD daily is a little bit more creamy and also awesome! They don’t pay me to sell their product, but I recommend it to so many people that they probably should.

screen-capture-5

Easy Sun Tips
– Use a sunscreen with at least SPF 30 that is Broad spectrum and apply every couple hours.

– Avoid mid day sun hours from 10 am- 2 pm if possible when scheduling activities like a hike or a Tee time.

– Wear sun protective clothing with a UPF rating. It really works and believe it or not J crew even has sun shirts!

-Get a moisturizer with SPF so that you can get into the habit of applying daily, even in the dead of winter.
– Wear hats and sun glasses whenever possible. They have so many cute styles that this one is pretty easy and if you are going to be out for awhile the bigger the brim, the better.

screen-capture-3screen-capture-1screen-capture-6

 

Photoaging

 

Aging is a complex and progressive process, and it is inevitable. One of the easiest and most effective things you can do to keep your skin looking healthy and youthful for longer is to protect it from the sun. Or more specifically, from the spectrum of ultraviolet (UV) radiation which can be either from the sun or from other synthetic sources.

Chronic UV radiation causes a variety of age related changes in the skin. It causes mutations in the DNA of the skin cells. It causes reactive oxygen species that can cause damage throughout the skin cell. It also causes freckles and pigmentary alterations, thinning of the skin, fragile blood vessels, and reduced elasticity. These changes of functionality result in changes in appearance, like wrinkles, uneven color or texture, drooping skin, dilated superficial blood vessels, and an increased pore size.

Collectively these changes in the skin are known as photoaging or sun damage. And the appearance of photoaging in some people can be quite dramatic. There are several interesting pictures floating around on the internet that illustrate the effects of sun damage on physical appearance quite nicely. The included photo is of  a truck driver with decades worth of sun exposure to the left side of his face, while the right side remained relatively protected in the truck. Notice the difference in drooping of the skin, the depth of the wrinkles.

One sided sundamage in truckdriver Bill Elliot

While photoaging happens to some degree in all skin types, it is particularly striking in those with lighter skin. Lighter skin lacks the natural protection that skin pigment provides and is inherently more susceptible to UV damage.

So this is where I make a plug for sunscreen. And try to dissuade you from tanning on a regular basis. Using regular sun protection guards the skin against the damage caused by UV radiation. Not only will this help protect your skin from developing skin cancer, but it will also keep it looking young and health for a longer time. Use sun protection!

The stuff that lives on us!

A diverse collection of microorganisms, bacteria, fungi, viruses, and other bugs live on the human skin. In fact, in our bodies microbial cells are reported to outnumber our own 10 to 1. This group of resident flora and fauna makes up what we refer to as the “microbiome”, and it’s no secret that these little guys can have a big effect on your health and immune system.

The human microbiome is both diverse and dynamic, varying from person to person and changing throughout life’s course. And it is becoming increasingly apparent that the microbiome is a prime target for manipulation and treatment in various conditions. While this knowledge is not particularly new, our methods for investigating are. New sequencing technologies have revolutionized the way we can study microbial communities. This gives us a better understanding of the nature and composition of the healthy skin microbiome, and we are learning more about how it is disturbed in various disease states. This puts the development of exciting new therapies targeting these bugs on the horizon.

What is the role of the microbiome in aging skin?

This is unclear, but postulating is always fun. We all know or have heard about the benefits of probiotics for the GI tract. There is a healthy microbial balance in the gut that is anti-inflammatory and it is foreseeable that certain metabolites released by the natural bacteria on the skin provide a similar anti-inflammatory effect helping to prevent discoloration, sun damage, and wrinkle formation.

Too much sweating? MiraDry could be your cure.

Excessive sweating beyond that which is required to regulate body temperature is medically termed hyperhidrosis. It is estimated to affect over 3% of the US population, which is quite common as far as medical conditions go. And according to quality of life studies, few medical conditions that are this common have as significant an emotional and social burden as hyperhidrosis. The most commonly affected body sites include palms, soles, armpits, face and scalp. These are also areas that are naturally high in sweat gland density.

Hyperhidrosis can be primary or idiopathic, which means it occurs without any apparent cause. Or it can be secondary, meaning that it is the result or side effect of something else like medications, hormonal changes, or other illnesses. It can also be localized to one area of the body, just on the hands for example, or it can be generalized with increased sweating from many areas of the body together. When hyperhidrosis is secondary it is usually generalized, affecting many areas of the body.

How do you know if you have primary hyperhidrosis? Check out the diagnostic criteria:

  1. You have Excessive sweating of 6 months or more located in axillae, palms, soles or craniofacial region
  2. There is no apparent secondary cause, such as medications, endocrine, or neurologic disease.
  3. You also have two or more of the following characteristics:
  • Symmetric, affecting both sides of the body.
  • Not present during the night
  • Episodes occur at least weekly
  • Onset of the problem before the age of 26
  • There is a family history of excessive sweating
  • The sweating is so much that it impairs normal daily activities

How do we treat it?

There are various treatments including topical solutions, systemic medications, and a variety of procedures. I’ll review a few of them very briefly.

Topical treatments are the first thing to try. There are several possible topical options, but the most common are prescription strength medications with up to a 20% Aluminum Chloride solution. These are often cheap and quite effective, but occasionally irritating to the skin.

Iontophoresis is another option, most often used for hyperhidrosis affecting just the palms or the soles.  It is a technique that involves immersion of the palms or soles in small, electrode-containing plastic trays with tap water. A very mild electric current is applied. This, we think, helps force sodium and other ions from the water into the sweat gland openings, forming plugs that restrict release of sweat from the ducts. Side-effects including minor discomfort during treatment and skin irritation such as burning, tingling and erythema rarely occur. The amount of time required for therapy is sometimes bothersome to patients, as each session is given over 20 min and it is necessary to treat at least a few times a week in order to maintain improvement.

Botox, Botulinum toxin, is a great way to treat focal areas of hyperhidrosis. It is a neuromodulator that works to stop nerves from firing by blocking presynaptic acetylcholine release. Since the nerves that activate the sweat glands are controlled by acetylcholine release, Botox does a nice job at decreasing sweat gland production. Botox injections are less invasive than surgical procedures and provide longer-lasting results than topical therapies. The effects last for 4–9 months on average and are associated with a very high satisfaction rate among patients.

This brings me to microwave energy, the motivation for the post. It is an exciting new therapy for excessive underarm sweating. The technology is called MiraDry, and there is nothing else out there like it. MiraDry uses microwave technology to permanently destroy the sweat glands in the armpits, and it is getting a lot of press these days in the cosmetic medical literature. It is approximately a one-hour procedure done in the clinic under local anesthesia to both armpits. Up to 80% of the sweat glands are destroyed after just one treatment, but two treatments appear to be required to achieve optimal results. Biopsies performed on skin treated up to one year previous have shown marked decrease in sweat glands, and since sweat glands are thought to not regenerate, this seems to support the company’s claims of long-term results. Side effects include transient swelling, discomfort and numbness, as well as redness, bruising, and partial underarm hair loss. Of course, evolving data regarding safety, therapeutic settings, efficacy, side effects and long-term follow-up will continue, as this treatment option is relatively new.

But the patients that I’ve treated are extremely pleased with this approach and I love being able to offer a treatment with such positive and potentially permanent results.

  

Pollution and graceful aging

Some people age gracefully, some do not. Why is that? The answer is quite complex, with genetics, personality, stress, environment, diet, and exercise all playing a likely role. A recent article in the Journal of Cosmetic Dermatology discusses the role of pollution in aging and skin health.

We’ve all heard stories of persons in rural areas across the world living for over a century robustly and in good health. Such observations have always incited speculation and investigation. These kinds of inquiries have led to multiple diet plans and health movements. But it makes sense on multiple levels that maybe avoiding pollution is also a key component to graceful aging. 

Pollution, particularly pollution from various forms of combustion, creates nanoparticles and reactive oxygen species in the atmosphere. These are toxic in that they cause damage and mutations in various regions of each cell’s DNA.  

A portion of DNA that directly correlates to aging is the telomere.  Telomeres are pieces of DNA found on the end of chromosomes (a large unit of DNA) that are designed to protect the ends from degrading. The shorter the telomere gets, the older the cell is.  And it is possible that this DNA damage predisposes the skin to premature aging.

Thankfully, there are many ways to help combat these effects such as healthy diets high in antioxidants and diligent sunprotection. Also, there are many easy and noninvasive procedures that work nicely to correct and improve the signs of aging and damage. Chemical peels and a variety of laser and light treatments are quick and effective ways to cosmetically treat the signs of aging that combustible pollution and ultraviolet radiation can cause.  

However, there is no treatment that works as well as prevention.  And while avoiding pollution may be impractical for many and impossible for some, your skin will certainly thank you for trying.

Noninvasive fat reduction?

You may have seen or heard of the many different machines and treatments now available in spas and cosmetic physicians office’s for non invasive fat reduction. Sometimes touted as easier nonsurgical options to the more invasive traditional liposuction, these treatments claim to help you lose fat without the downtime. You’ve seen the advertisements or otherwise heard of these machines right? If you haven’t, check them out. I’ll name just a few: CoolSculpt, Zerona, iLipo, Thermage, Ulthera, and Liposonix.  If you have heard of some of these and you’re still confused, don’t worry. I think many physicians are too.

In recent years, a number of different treatment modalities have become available for the noninvasive reduction of adipose or fat tissue, and the discerning patient is bombarded by claims of quick fix options and promises of dramatic results. A lot of different energies are employed by these various devices. Whether it’s cryolipolysis, radiofrequency, low-level laser, or high-intensity focused ultrasound, advertisements and sales representatives may be hard to interpret, as most of these biased sources leave us thinking that these treatments sound too good to be true. Honestly, I think many of them probably are.

Each technology employs a different mechanism of action to try to get rid of the fat. Some Heat or burn, some freeze, and some claim to poke holes in the targeted fat cells. Among the previously mentioned technologies, cryolipolysis, popularly known as CoolSculting, freezes the fat. Not only has this treatment been commercially available for the longest time, but it has also, in my opinion, has been the best researched.

The principle behind cryolipolysis is based on the fact that fat cells are more susceptible to the cold than other cells in the skin. Thus, the precise and careful application of cold temperatures can trigger the death and slow clearing of the treated fat cells, without causing significant damage to the overlying skin.

In clinical studies, cryolipolysis was shown to reduce subcutaneous fat at the treatment site by up to 25% after one treatment. Improvements are generally seen in over 80% of treated subjects, and patient satisfaction rates are relatively high.

Cryolipolysis has been proven to be a safe method for targeted fat reduction, or “body contouring”, and is accomplished with only minimal discomfort in the vast majority of cases. Expected side effects include temporary redness and bruising. Occasionally, transient numbness will occur in the treated area. If this happens, it usually resolves within 2 weeks. Rarely, late-onset pain, occurring about 2 weeks post-procedure, is reported. This resolves without intervention.

I find these technologies fascinating, and while many have not yet made me a believer. I’m sure to be revisiting this topic.